Healthcare Provider Details

I. General information

NPI: 1730511460
Provider Name (Legal Business Name): MARK ANTHONY LAGO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARK ANTHONY GALAN LAGO

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W MONEE MANHATTAN RD STE 115
MONEE IL
60449-8866
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 708-314-7761
  • Fax:
Mailing address:
  • Phone: 630-575-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.019839
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: